Colorectal cancer surveillance: What's new and what's next?

Table 1 Five-year surveillance regimens tested in reviewed randomized controlled trials

	Enrollment period	Setting	Stages included	Type of regimen	Surveillance regimen
Ohlsson et al[15]	1983-1986	2 Swedish centers	Dukes A, B, C	Intensive	History and physical exam, rigid proctosigmoidoscopy, CEA, Alk Phos, liver function tests, fecal hemoglobin, and chest X-ray at 3, 6, 9, 12, 15, 18, 21, 24, 30, 36, 42, 48 and 60 mo; endoscopic visualization of the anastomosis at 9, 21, and 42 mo; complete colonoscopy at 3, 15, 30 and 60 mo; pelvic CT (rectal cancer only) at 3, 6, 12, 18 and 24 mo
				Minimal	No structured follow-up. Advised to obtain fecal hemoglobin tests every 3 mo for 2 years, then annually. Instructed to seek care if a series of warning signs/symptoms were experienced
Mäkelä et al[16]	1988-1990	1 Finnish center	Dukes A, B, C	Intensive	History and physical exam CEA, CBC fecal hemoglobin at 3, 6, 9, 12, 15, 18, 21, 24, 30, 36, 48, 54 and 60 mo; Flexible sigmoidoscopy (if rectal/sigmoid tumors) every 3 mo; Liver ultrasound every 6 mo; Colonoscopy and liver CT annually
				Minimal	History and physical exam CEA, CBC fecal hemoglobin, CXR (and rigid sigmoidoscopy if rectal cancer) at 3, 6, 9, 12, 15, 18, 21, 24, 30, 36, 42, 48, 54, 60 mo; Barium enema at 12, 24, 36 48 and 60 mo
Kjeldsen et al[17]	1983-1994	A single Danish county	Dukes A, B, C	Intensive	History and physical exam including digital rectal exam and gynecologic exam, hemoglobin, erythrocyte sedimentation rate, liver enzymes, fecal hemoglobin, colonoscopy, and chest X-ray at 6, 12, 18, 24, 30, 36, 42, 48, 54, 60, 120, 150 and 180 mo
				Minimal	The same investigations as above, but only at 60, 120, and 180 mo
Pietra et al[18]	1987-1990	1 Italian center	Dukes B, C	Intensive	History and physical exam, liver ultrasound, and CEA at 3, 6, 9, 12, 15, 18, 21, 24, 30, 36, 42, 48, 54, 60 mo; CT, Chest X-ray and colonoscopy annually
				Minimal	History and physical exam, liver ultrasound, and CEA at 6, 12, 24, 36, 48, and 60 mo; Chest X-ray and colonoscopy annually
Schoemaker et al[19]	1984-1990	Multiple Australian centers	Dukes A, B, C	Intensive	History and physical exam, CEA, CBC, liver function tests, and fecal hemoglobin at 3, 6, 9, 12, 15, 18, 21, 24, 30, 36, 42, 48, 54, 60 mo; Chest X-ray, liver CT, and colonoscopy annually
				Minimal	History and physical exam, CEA, CBC, liver function tests, and fecal hemoglobin at 3, 6, 9, 12, 15, 18, 21, 24, 30, 36, 42, 48, 54, 60 mo; Chest X-ray, liver CT, and colonoscopy at 60 mo
Secco et al[20]	1988-1996	1 Italian center	Low-risk	Intensive risk-adapted	History and physical, CEA, abdominal/pelvic ultrasound at 6, 12, 18, 24, 36, 48, and 60 mo; Chest X-ray annually; Rectal cancer only: Rigid proctosigmoidoscpy at 12, 24 and 48 mo
				Minimal	Telephone follow-up every 6 mo; History and physical exam annually
			High-risk	Intensive risk-adapted	History and physical and CEA at 3, 6, 9, 12, 15, 18, 21, 24, 28, 32, 36, 42, 48, 54, and 60 mo; Abdominal/pelvic ultrasound at 6, 12, 18, 24, 30, 36, 48 and 60 mo; Rigid proctosigmoidoscopy (rectal cancer only) and chest X-ray annually
				Minimal	Telephone follow-up every 6 mo; History and physical exam annually
Rodríguez-Moranta et al[21]	1997-2001	3 Spanish centers	TNM II and III	Intensive	History and physical, CEA, CBC, and liver function tests at 3, 6, 9, 12, 15, 18, 21, 24, 30, 36, 42, 48, 54 and 60 mo; Abdominal/pelvic CT (rectal cancer only) or Abdominal ultrasound (colon cancer only) at 6, 12, 18, 24, 36, 48, 60 mo; Chest X-ray and colonoscopy annually
				Minimal	History and physical, CEA, CBC, and liver function tests at 3, 6, 9, 12, 15, 18, 21, 24, 30, 36, 42, 48, 54 and 60 mo; Colonoscopy at 12 and 36 mo

CEA: Carcinoembryonic antigen assay; CBC: Complete blood count; Alk phos: Alkalilne phosphatase; CT: Computed tomography.

Table 2 Results of reviewed randomized controlled trials of colorectal cancer surveillance strategies n (%)

	Type of regimen	n	Stages1	Rectal cancer	Follow-up time	Recurrences2	Symptoms were first sign of recurrence	Time to recurrence(mo):mean ± SD /median	Reoperated (% of recurrences)	Overall survival at 5 yr	Cancer-related survival at 5 yr	Survival of recurring patients 5 yr after first treated
Ohlsson et al[15]	Intensive	53	A/B/C: 19%/40%/41%	36%	6.8 yr median	17 (32)	8 (47)	20	5 (29)	75%	78%	29%
	Minimal	54	A/B/C: 17%/48%/35%	31%	(overall)	18 (33)	15 (83)	24	3 (17)	67%	71%	22%
Mäkelä et al[16]	Intensive	52	A/B/C: 24%/46%/29%	31%	NR	22 (42)	3 (14)	10 ± 5	5 (22)	59%	NR	NR
	Minimal	54	A/B/C: 28%/44%/28%	28%	NR	21 (39)	4 (19)	15 ± 10	3 (14)	54%	NR	NR
Kjeldsen et al[17]	Intensive	290	A/B/C: 23%/51%/26%	46%	55% still followed at 5 yr (overall)	813 (28)	38 (47)	18	17 (21)	70%	78%4	NR
	Minimal	307	A/B/C: 23%/47%/30%	49%		833 (27)	59 (71)	27	5 (6)	68%	78%4	NR
Pietra et al[18]	Intensive	104	A/B/C: 0%/60%/40%	30%	100% still followed at 5 yr (overall)	41 (39)	105 (42% of local recurrences)	10.3 ± 2.75	21 (51)	73%	NR	38%
	Minimal	103	A/B/C: 0%/58%/42%	36%		426 (41)	105 (83% of local recurrence)	20.2 ± 6.15	6 (14)	58%	NR	0%
Schoemaker et al[19]	Intensive	167	A/B/C: 25%/47%/28%	28%	NR	56 (34)	NR	NR	6 (11)	77%4	NR	NR
	Minimal	158	A/B/C: 19%/48%/33%	26%	NR	64 (41)	NR	NR	5 (8)	70%4	NR	NR
Secco et al[20]	Low-risk–risk-adapted	84	A/B: 100%	NR	Median 42 mo	27 (32)	32%7	16	6 (22)	80%	NR	NR
	Low risk–minimal	61	A/B: 100%	NR	NR	25 (40)	75%7	14	6 (24)	60%	NR	NR
	High-risk–risk-adapted	108	A/B: 36%	NR	Median 61.5 mo	74 (68)	32%7	13.5	25 (34)	50%	NR	NR
			C: 64%
	High risk–minimal	84	A/B: 20%C: 80%	NR	NR	58 (69)	75%7	8	7 (12)	32%	NR	NR
Rodríguez- Moranta et al[21]	Intensive	127	II: 60%	23%	Median 49 mo	35 (27)	NR	39 ± 21	18 (51)	75%4	NR	NR
			III:40%
	Minimal	132	II: 61%	28%	Median 45 mo	34 (26)	NR	38 ± 19	10 (29)	73%4	NR	NR
			III:39%

¹A, B and C refer to Dukes staging, while I, II and III refer to TNM staging;

²Includes metachronous colorectal cancers (CRCs);

³Includes 7 cases of metachronous CRC in the intensive group and 3 in the less intensive group;

⁴Estimated visually from survival curve;

⁵Reported for local recurrences only;

⁶Includes 1 case of metachronous CRC;

⁷Reflects combined high-risk and low-risk groups. NR: Not reported; “Overall” describes all trial arms combined.

Table 3 Summary of United States and European colorectal cancer surveillance guidelines

	ASCO[33]2005	ASCRS[34,35]2005	NCCN[36,37]2014	Denmark[38] 2009	Norway[39]2012	United Kingdom[40]2010
Stage	II-III	I-III	I-III	II-III	II-III	I-III
History and physical	q3-6 mo × 3 yr; q 6 mo in year 4-5	At least q4 mo × 2 yr	q3-6 mo × 2 yr; q6 mo in year 3-5	At 1 mo	q6 mo × 3 yr, q12 mo in year 4-5	None
CEA	q3 mo × at least 3 yr	At least q4 mo × 2 yr	q3-6 mo × 2 yr; q6 mo in year 3-5	At 1, 12 and 36 mo	q6 mo × 3 yr, q12 mo in year 4-5	None
CT chest	Annually × 3 yr if high risk	None	Annually up to 5 yr if high risk	At 12 and 36 mo	Annually × 5 yr	None
CT abdomen/ pelvis	Annually × 3 yr if high risk	None	Annually up to 5 yr if high risk	At 12 and 36 mo	At 6 mo and 5 yr	Once within first 2 yr
CEUS liver	None	None	None	None	At 12, 18, 24, 30, 36 and 48 mo	None
Colonoscopy	At 3 yr and q5 thereafter	q3 yr	At 1 and 4 yr, then q5 yr	None	At 5 yr;or CT colonography at 5 yr	q5 yr

NCCN: National Comprehensive Cancer Network; ASCO: American Society of Clinical Oncology; ASCRS: American Society of Colon and Rectal Cancer Surgeons; UK: United Kingdom 2010 guidelines; Nor: Norwegian 2012 guidelines; CEUS: Contrast-enhanced ultrasound; CEA: Carcinoembryonic antigen; CT: Computed tomography.